PowerPoint Presentation

Screen-and-TreatA new strategy to prevent cryptococcal deaths

Youve now heard about the new WHO guidelines for management of cryptococcal meningitisYouve also heard about the excellent performance of the new LFA and seen it first hand My job is to take you through the new strategy to prevent cryptococcal meningitis and associated deaths which pivots on the use of the LFA as a screening tool 1Preventing cryptococcal deathsAssembling a customised screen-and-treat toolboxWorking towards implementation of screening in your settingWeighing up strategies to prevent cryptococcal deathsDr Nelesh GovenderHIVCS MeetingNICD/ NHLS2During this talk, Ill weigh up strategies for prevention of cryptococcal disease and then focus on the screen-and-treat approach Based on our experience in South Africa, Ill also discuss practical steps for implementation of a screen-and-treat programme High, early mortality among HIV-infected adults on ART in sub-Saharan Africa

Lawn S, et al. AIDS. 2008Dr Nelesh GovenderHIVCS MeetingNICD/ NHLS3The high early mortality within ART programmes is a major challenge in many Sub-Saharan African countries Between 8%-26% of patients will die in the first year after initiating ARTWhat is particularly concerning is that although virological and immunological responses are equivalent in high-income and resource-limited settings, the early mortality is much higher in RLS Most deaths occur in the 1st few months especially in the gap between identification of patients for ART initiation and actual ART initiation Common cause of death include TB, cryptococcal meningitis (20%!), acute bacterial sepsis, malignancies and wasting syndromeThree-pillared strategy to reduce deathsEarlierHIVdiagnosisPrevent and treatopportunistic infectionsEarlierantiretroviral treatmentLawn S, et al. AIDS. 2008Dr Nelesh GovenderHIVCS MeetingNICD/ NHLS4Three strategies have been described to reduce early deaths in ART programmes Promote early HIV diagnosisStrengthen links between HIV diagnosis and ART to facilitate timely initiation of ARTPrevent, screen for and treat opportunistic infections Prevent cryptococcal deathsAntiretroviral treatment Antifungal drugsDiagnostic testsUp-to-date guidelines for clinical management of meningitisPublic health surveillance Screen-and-treatPrimary prophylaxis

Preventing cryptococcal deaths is possible through access to and implementation of a package of interventions screen-and-treat is not a magic bullet that would work in isolation Death prevention requires access to ART, antifungal drugs and diagnostic tests and guidance to use these tools appropriately Primary prophylaxis and screen-and-treat are 2 approaches along the same continuum to prevent meningitis and the deaths associated with this condition Id like to briefly weigh up the evidence for primary prophylaxis vs. screening

5How does screening compare to primary prophylaxis?Primary prophylaxisTreat all HIV/AIDS patients with CD4